Thursday, November 20, 2008

In search of a doctor (and the system)

Again, it's been a long time since I posted - apologies! Also, considering the record length of my posts, I'll try to post shorter, more reflective pieces from now on!

August 2008

The orientation at CHC had given us a thorough introduction to Community Health. But in Sitapur, given that Sangtin Kisaan Mazdoor Sangathan's (SKMS) primary work was in mobilizing for NREGA, I did not plan on sharing my learnings at their meetings. My plan was to discuss these issues with a few people and then see what came through. However Mukesh, who serves in an advisory role with SKMS, suggested that I speak about health at the regional meetings using one or two talking points, thus starting the thought process in this important topic. Other SKMS members concurred, so I raised the issue at the Aug 10th and 11th meetings in Aant and Qutubnagar respectively. We discussed why it is easier, or rather more natural, to work on livelihoods, BPL etc. than on health – we only think about the health system when we are sick, knowledge and power are concentrated in the hands of medical professionals etc.

I asked the assembled people, about 100-150 in each meeting, to think about health-related issues and come up with one or two that they would want to work on. While everyone was mulling over this, a few people raised the issue of malaria. At this, others began speaking up about their own and their village's situation. From there, matters progressed very quickly, and before I knew it, plans were being made to prepare lists of people affected by malaria and to demand action at the block level.

I was not sure what to do with the information being collected, so contacted CHC. Armed with their advice, I went to meet Richa. She was quite concerned with the various illnesses prevalent in SKMS villages this monsoon. She felt that camps should be organized in a few central villages so that all the sick could easily access health services. We decided that I would meet the chief doctor in Mishrikh where a CHC (Community Health Centre) is based.

But first, a brief description of the area: the Mishrikh CHC serves most of Mishrikh block, with some villages as far as 20 km away. The average cost of travel one-way is Rs. 10. If the patient needs to be escorted, travel costs themselves could be as high as Rs. 40. Further, patients need to get to the CHC before noon to get a 'parcha' or token that would allow them to see the doctor, get medicines etc. Transportation in the form of tempos is not very reliable and if one is late, the entire day is wasted. In contrast, Qutubnagar, one of the big villages, is more accessible for the people in that area and has one MBBS doctor who charges ~Rs. 40 / diagnosis and a couple of 'Jhola chhaap' doctors who charge even less. But inspite of this, the Mishrikh CHC is well used as I discovered when I visited it on August 19th.

The chief doctor was not available – he was on leave till the 28th, the day after we were scheduled to leave Sitapur. Further, the situation was dire in many villages – just that morning, we had heard that the entire Dalit 'basti' in Kunwarapur was inundated with both lake and canal water. There and elsewhere, many houses had collapsed and people were exposed to the rains with nothing to protect them but plastic sheets. While I was in Mishrikh, Dwiji had gone to Kunwarapur and was wading through knee-deep water helping to document the damage.

On further enquiry, I found the junior-most doctor on service. He was swamped with patients. While watching him interrogate each patient briefly and jot down a prescription, I was reminded of Adithya recounting his health camp experiences at CHC Bangalore. In such a situation, the doctor can spend at most half a minute on diagnosis. It has got to be dehumanizing to treat patients as if they were parts on an assembly line. I managed to speak briefly to the doctor and ask him what planning the Health department did for malaria and other diseases in the monsoon. He looked at me like I was delirious – 'We are here treating patients – that's what we do!' I then asked what would warrant a personal visit by a team of doctors to a village. 'A serious outbreak of diarrhea or something equally contagious and life-threatening' was his reply before he was engulfed by patients again.

Given the lack of progress at Mishrikh, I went to the District Hospital in Sitapur the next day hoping to get more answers. Here, I was luckier – the additional CMO (Chief Medical Officer) and the Deputy CMO were both in the office and the latter was in a chatty mood. He talked about the staffing problems in the district – there was a shortage of at least 30 doctors. Government service and a rural lifestyle cannot compete with the salaries and career growth possible in urban settings. Currently, even C-sections had to performed in the District Hospital as there was no anesthesiologist at the CHC. They were under-equipped for normal times, let alone catastrophic situations. He then went off on a slight rant about how ignorant and lazy villagers were and how hard it was to treat them. These were comments similar to what I heard the past couple of days from private doctors in Qutubnagar – the path of least resistance in this thankless situation seems to be blaming the victims.

When pushed on health camps, the Deputy CMO said that a team would visit a village only in exceptional circumstances. Usually, there was a good reporting structure in place and news of outbreaks almost always reached them. In fact, in some situations, they had gone to villages and found that the situation there was not as dire as expected. Such visits were detrimental since the team could have spend their time better in the hospital treating the patients who arrived there.

After this discussion, I came to the conclusion that it would be very hard to get a medical team to visit any of the SKMS villages. Other areas in the district were in worse shape – in some blocks, villagers were practically living on the roads as all other areas were flooded. Nevertheless, I communicated this information to the SKMS team and they did try to get a team to visit Kunwarapur.

Two days later, we went to visit Reena and Shammu at Kunwarapur. No medical team had come to assess the situation. But we learnt that, in a nearby village, 7 children had died from diarrheal-related causes the previous day. So much for a good reporting structure...

But given the dire state of the Health system and the realities of rural life here in Sitapur and elsewhere, many such tragedies are in the making...

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